The advantages and disadvantages of long-acting reversible contraception (LARC)

Anna Glasier (GB)

[Glasier] University of Edinburgh, Edinburgh

Long-acting reversible contraception (LARC) is in vogue. The definition for most experts includes contraceptive implants and intra-uterine devices (copper and hormonal). Injectable contraceptives such as Depo-Provera are often not classified as LARC as these methods can be discontinued by the user (and often are). LARC have advantages and disadvantages but the views of providers and potential users differ. The long-acting nature of the methods is seen by some users (particularly young women) as off-putting, while providers regard this as an important attribute. The need for insertion by a skilled provider is a disadvantage for public health programmes since skilled providers are often scarce and always expensive. The need for removal by a skilled provider however is part of the reason for the high efficacy of LARC since discontinuation of the method requires motivation and action (in contrast to other methods of contraception which are often discontinued through inertia). Some LARC are expensive with respect to upfront costs but all are highly cost effective even after just one year of use because of their effectiveness in preventing unintended pregnancies and abortions. Copper IUDs are by far the most cost-effective methods of contraception available. In many countries LARC methods are not popular among potential users. Many women dislike the 'idea' of an intrauterine device and the prospect of insertion of an implant is daunting for others. For providers however LARC are the 'holy grail' because of their effectiveness in preventing unintended pregnancy. Until very recently the almost universal finding that couples using LARC had significantly higher continuation rates and lower unintended pregnancy rates came from observational studies. However a recent randomized trial of LARC versus short-acting reversible contraceptives (SARC), showed that when randomized to receive and implant or an IUD, women who initially asked for a less effective contraceptive method had higher continuation rates and fewer unintended pregnancies than women randomized to receive the method that they had initially sought. (1) References 1. Hubacher D, et al. Long-acting reversible contraceptive acceptability and unintended pregnancy among women presenting for short-acting methods: a randomized patient preference trial. Am J Obstet Gynecol 2017;216: 101-09.